Procedure. Applies To: UNM Hospitals Responsible Department: Quality Revised: 03/2014

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1 Procedure Patient Age Group: ( ) N/A ( ) All Ages ( ) Newborns (X) Pediatric (x ) Adult DESCRIPTION/OVERVIEW UNM Hospitals (UNMH) is recognized as a large academic health care system providing services to unique populations in a variety of clinical settings. The intent of this policy is to describe procedures for identifying individuals at risk for suicide and to provide protection for the patient s emotional and physical health in a safe environment with appropriate interventions. Screening patients for suicide risk and providing appropriate intervention is not a one size fits all process, and will be accomplished through procedures that are specific to the clinical setting and patient circumstances while meeting the elements of this policy. REFERENCES American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (DSM) Fifth Edition. Becker, K., Schmidtke, H. (2010) All along the watchtower: suicide risk screening, a pilot study. Nursing Management. 41(3), Centers for Medicare and Medicaid Services (CMS) (c)(2) Statistics and Epidemiology Unit of the Bureau of Vital Records and Health Statistics. (2009). New Mexico Selected Health Statistics Annual Report The Joint Commission. (2010). A follow-up report on preventing suicide: Focus on medical/surgical units and the emergency department. The Joint Commission Sentinel Event Alert. Issue 46. The Joint Commission (2014). NPSG US Department of Health and Human Services (HHS) Office of the Surgeon General and National Action Alliance for Suicide Prevention National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington, DC: HHS, September 2012 AREAS OF RESPONSIBILITY UNMH-Staff & Providers Applies To: UNM Hospitals Responsible Department: Quality Revised: 03/2014 PROCEDURES 1. Patients presenting to UNMH psychiatric hospitals, and any patient presenting to any UNMH facility with a primary diagnosis or complaint of an emotional or behavioral disorder, will be screened for suicidality appropriate to the clinical area and patient circumstances. 2. If the patient indicates a risk for suicide during the screening, immediate safety needs will be met a risk assessment will be completed by a licensed independent practitioner (LIP). If the LIP is not available to perform the risk assessment or deems that further care is necessary a clinical member of the patient s primary treatment team, a clinician with the patient s medical home, or an on-call mental health provider may be contacted for further guidance. 3. When a patient who was at any point in time identified as having been at elevated risk for suicide during the hospital stay/clinic visit is discharged from the hospital and/or clinic, suicide prevention information, such as a crisis line number, and/or next follow up appointment, will be included in the discharge instructions to the patient (and/or family member). a. In the event that a person calls a UNMH facility and threatens suicide, UNMH staff should attempt to collect the person's name, location, contact phone number, and any details regarding the method of suicide. Under most circumstances, the local law Page 1 of 5

2 enforcement agency should be contacted. These police agencies can evaluate the patient's well-being. Suggesting a Crisis Intervention Team (CIT) officer involvement may be appropriate. b. If the patient is known to be on UNM Campus, please call UNM PD at IMPLEMENTATION PROCEDURE BY AREA Outpatient Clinics 1. Patients are not routinely screened for suicide risk in the outpatient clinic setting; however, patient circumstances may indicate the need for suicide risk assessment. 2. In the outpatient clinic setting, suicide risk assessment is the responsibility of the LIP. 3. If any staff member suspects a patient might be a suicide risk, any available LIP will be notified immediately to further assess the patient. 4. A staff member will remain with the patient until the patient can be handed off safely to a LIP. If a LIP is not immediately available, the clinic Social Worker Case Manager should be notified to assess the patient and will collaborate with the LIP when the LIP is available. 5. If the patient is actively discussing suicide, escalating or becoming increasingly difficult to comfort or talk down, consider calling 911 for off-site locations without shuttle service or UNMH security for off-site locations with shuttle service or on-site locations, to assist in keeping the patient safe. 6. If a LIP determines that further evaluation or treatment by a mental health provider is beneficial, the patient s primary care team or the mental health providers assigned to the location are to be involved. Based on clinical assessment of suicide risk level, the decision may include involvement of emergency services, including UNM Psychiatric Emergency Services (PES). If there is no LIP present to assess suicide risk, a licensed healthcare professional will attempt to contact the patient s primary care provider (PCP) for guidance. If the PCP is not immediately available, a clinical member of the patient s primary treatment team, a clinician with the patient s medical home, or an on-call mental health provider may be contacted for further guidance. 7. If it is determined that the patient needs to be transferred to another location for care: a. Transfer will occur via ambulance or other suitable mode of transfer as determined by the LIP. Each transfer will follow established transfer guidelines. i. UNMH security escort is only available for occurrences at locations with UNMH shuttle service. 8. If a patient refuses transfer for further evaluation, the following options are available: a. The LIP should be notified to discuss options such as issuing a Certificate for Evaluation. A Certificate for Evaluation may only be issued by licensed physicians or certified psychologists (refer to UNM Psychiatric Center guideline Certificate for Evaluation). If the LIP is not immediately available, an on-call mental health provider may be contacted for further guidance. b. Ask patient to sign an Against Medical Advice form and allow the patient to leave the clinical setting and notify the appropriate law enforcement agency. Hospital Inpatient and Emergency Department 1. The primary team physician or licensed LIP is responsible for ordering the suicide precautions, 1:1 observation by a patient observation assistant (POA), and a psychiatric evaluation when assessment indicates elevated suicide risk. a. If a physician or licensed LIP is not available, a licensed nurse may initiate 1:1 observation based on appropriate assessment of the patient. 2. The suicide precaution order will initiate the assessment and monitoring tasks for the nurse. The LIP is also responsible for discontinuing the order. Page 2 of 5

3 3. The nurse caring for the patient that has been placed under suicide precautions is responsible for completing and documenting the suicide assessment at least once per shift. 4. Patients on pediatric units will have a laminated sign placed on the door to their room to alert staff of the precautions. The sign will have the start date written on it. 5. The nurse will conduct an environmental assessment and document once per shift which includes: a. Removal of all hazardous objects: scissors, matches, razors, belts, glass, metal coat hangers, lighters, plastic bags, cords/call lights, shoelaces, and any other sharp items. b. Hazardous items belonging to the patient s roommate are kept out of the common areas, such as the bathroom. c. The sharps container should be no more than ½ full. d. Patient belongings, including clothing and shoes, have been removed from the room. e. POA at bedside. f. Meals are to be placed on isolation trays, and the nurse needs to verify that patient receives paper products and plastic utensils. g. Pediatric patient meals may be ordered as finger foods only at the discretion of the LIP so that no utensils are required. 6. At any point during a patient s stay when elevated suicide risk is identified, the nurse responsible for caring for the patient alerts the primary team physician and initiates precautions, including initial and routine assessments. This may only be discontinued by a LIP order. 7. The POA caring for a suicidal patient is responsible for maintaining a safe environment and observing the patient at all times, including any time off the unit and in the bathroom. Refer to procedure Patient Observation Procedure for Adult and Pediatric Patients. 8. Patients with a suicide precaution order from Emergency Department (ED) must have a POA prior to admission to an inpatient unit. Emergency Department 1. The nurse or provider will initiate appropriate safety precautions. 2. Based on suicide risk assessment level, a patient s visitors may be limited at the discretion of the RN Supervisor or LIP. Inpatient Units, intubated patients: 1. Patients admitted to the Intensive Care Unit for suicide attempt that require mechanical ventilation and sedation will not have suicide precautions ordered, however a psychiatric consult will be requested at admission. Suicide precautions and a POA must be ordered as soon as the patient is extubated. Inpatient Units, non-intubated patients: 1. Every reasonable attempt will be made to place the adult patient in a bed by the room door, near the nurse s station, with a roommate. 2. The patient will be assigned a POA; family members may not be used to observe the patient. A staff member must stay with the patient until a POA arrives. 3. The patient will be required to wear a hospital gown and have their belongings removed from the room and placed in a secure location on the unit. Individual items may be left with or returned to the patient at the discretion of their nurse. a. Pediatric patients may wear personal clothing at the provider s discretion and written order. Items that may be used for harm (e.g. belt, shoestrings, necklace, drawstrings, etc.) will not be allowed to remain with the patient. 4. Suicidal patients may not leave the unit except for treatments and testing ordered by a LIP. When travelling off the unit for treatment or testing, the POA must accompany the patients. a. Pediatric patients on suicide precautions may leave the unit for a medical exam or testing but must be accompanied by staff and may not be sent alone with the legal guardian. Page 3 of 5

4 5. The POA will monitor the patient at all times from approximately an arm s length away, including in the bathroom, during off unit activities, and when the patient has visitors. a. Pediatric patients are not allowed to be in the Child Life Center even if accompanied by a POA. b. Pediatric patients that present an elopement risk may be placed on the infant security system at the nurse s or provider s discretion. 6. Every reasonable attempt will be made to assign a POA of the same gender as the patient. 7. All visitors will be instructed to check in with the nurse prior to visiting the patient. The POA is to ask all visitors if they have checked in with the nurse. Any items brought to the patient by a visitor need to be inspected and approved by the nurse. 8. All assessments, interventions, and precautions taken are to be documented on the appropriate form in the EMR. Pediatric Patients 1. Exceptions for pediatric patients will be handled on a case by case basis and addressed with a medical order from the primary service. 2. A copy of the plan of care developed with child psychiatry will be placed into the bedside chart for clear communication to all other services. 3. All outpatient admissions from a referring psychiatric institution or residential care facility will be placed on suicide precautions until evaluated by Child Psychiatry. University Psychiatric Center Psychiatric Emergency Services (PES) and Psychiatric Urgent Care Clinic (PUCC) 1. All patients presenting to PES and PUCC are to be screened for suicidal risk level during triage and/or the LIP visit. 2. If the patient is assessed to be at high acute risk for suicide, the patient will be brought into PES where he/she will receive a security screening and unsafe items/contraband will be removed from the environment. The patient will be physically observed for safety at least every 15 minutes. 3. The patient shall remain in PES until the PES physician assesses and determines the patient disposition. 4. The RN will arrange disposition for the patient based on the PES physician and Treatment Team s plan (i.e., provide community resource information, referral to UPC services, prior authorization for inpatient admission as necessary) Adult Psychiatric Outpatient Services 1. Patients in the psychiatric outpatient setting are primarily seen by the psychiatric LIP and will be screened for acute suicide risk by the psychiatric LIP given the clinical area and patient circumstances. 2. If a patient s ongoing suicide risk assessment indicates a change in level, the psychiatric LIP will determine the most appropriate course of treatment. 3. If any staff member suspects a patient might be an elevated acute suicide risk, any available psychiatric nurse, therapist, or LIP will be notified immediately to further assess the patient. Adult Psychiatric Inpatient Services 1. All patients admitted to the psychiatric inpatient unit will be evaluated at first contact, with any subsequent suicidal behavior, increased ideation, or pertinent clinical change, prior to change in privileges, and at discharge. 2. If a patient is determined to be at elevated risk for suicide, the staff will refer to procedure: UNM PC Suicide Risk and Other Estimation and Monitoring. Children s Psychiatric Center Children s Psychiatric Outpatient and Access Services Page 4 of 5

5 1. Patients in the psychiatric outpatient setting are screened for suicide risk on admission to outpatient services and as needed by the psychiatric LIP, given the patient circumstances. 2. If a patient is determined to be at elevated risk for suicide, the psychiatric LIP will determine the most appropriate course of treatment. 3. If any staff member suspects a patient might be at an acutely elevated suicide risk, any available psychiatric nurse, therapist or other LIP will be notified immediately to further assess the patient. Children s Psychiatric Inpatient Services 1. All patients admitted to the psychiatric inpatient unit will be evaluated at first contact, with any subsequent suicidal behavior, increased ideation, or pertinent clinical change, prior to change in privileges, and at discharge. 2. If a patient is determined to be at elevated risk for suicide, the staff will refer to procedure: CPC Suicide Risk and Other Estimation and Monitoring. DEFINITIONS Emotional or Behavioral Disorders - for purposes of this document, the phrase emotional or behavioral disorders refers to any DSM Axis I clinical disorder or II personality disorder diagnosis or condition, including those related to substance abuse (see Attachment A for major categories of DSM Axis I and II diagnoses). Certificate for Evaluation a declaration, according to the Mental Health and Developmental Disabilities , by a peace officer, licensed physician or a certified psychologist that a person, as a result of a mental disorder, presents a likelihood of serious harm to self or others and that immediate detention is necessary to prevent such harm. This certification constitutes authority to transport the person to an evaluation facility without a court order. Licensed Independent Practitioner (LIP) - any individual permitted by law and by the organization to provide care and services, without direction or supervision, within the scope of the individual's license and consistent with individually granted clinical privileges. SUMMARY OF CHANGES Revised 09/2012 version to include UNMH RESOURCES/TRAINING Resource/Dep t Clinical Education Joan Deis Contact Information DOCUMENT APPROVAL & TRACKING Item Contact Date Approval Owner Executive Director, Quality and Patient Safety Consultant(s) Quality and Patient Safety, Chief Medical Officer, Clinical Administrators, Nurse Executive Directors, Executive Medical Directors, Risk Management, Clinical Affairs Committee(s) Clinical Operations PP&G Committee, Nurse Practice PP&G Subcommittee, Clinical Executive Committee, Medical Executive Committee Y Nursing Officer Sheena Ferguson, Chief Nursing Officer Y Medical Director Richard Crowell, MD, Chief Quality Officer Y Official Approver Erin Doles, Administrator, Professional and Support Services Y Official Signature Date: 5/8/2014 Effective Date 5/8/2014 Origination Date 7/2012 Issue Date Clinical Operations Policy Coordinator 5/9/2014 ar Page 5 of 5